Prevalence of co-existent COVID-19-associated pulmonary aspergillosis (CAPA) and its impact on early mortality in patients with COVID-19-associated pulmonary mucormycosis (CAPM).

BACKGROUND: Data on mixed mould infection with COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated pulmonary mucormycosis (CAPM) are sparse. OBJECTIVES: To ascertain the prevalence of co-existent CAPA in CAPM (mixed mould infection) and whether mixed mould infection is associated with early mortality (≤7 days of diagnosis). METHODS: We retrospectively analysed the data collected from 25 centres across India on COVID-19-associated mucormycosis. We included only CAPM and excluded subjects with disseminated or rhino-orbital mucormycosis. We defined co-existent CAPA if a respiratory specimen showed septate hyphae on smear, histopathology or culture grew Aspergillus spp. We also compare the demography, predisposing factors, severity of COVID-19, and management of CAPM patients with and without CAPA. Using a case-control design, we assess whether mixed mould infection (primary exposure) were associated with early mortality in CAPM. RESULTS: We included 105 patients with CAPM. The prevalence of mixed mould infection was 20% (21/105). Patients with mixed mould infection experienced early mortality (9/21 [42.9%] vs. 15/84 [17.9%]; p = 0.02) and poorer survival at 6 weeks (7/21 [33.3] vs. 46/77 [59.7%]; p = 0.03) than CAPM alone. On imaging, consolidation was more commonly encountered with mixed mould infections than CAPM. Co-existent CAPA (odds ratio [95% confidence interval], 19.1 [2.62-139.1]) was independently associated with early mortality in CAPM after adjusting for hypoxemia during COVID-19 and other factors. CONCLUSION: Coinfection of CAPA and CAPM was not uncommon in our CAPM patients and portends a worse prognosis. Prospective studies from different countries are required to know the impact of mixed mould infection.

Risk factors, mortality, and predictors of survival in COVID-19-associated pulmonary mucormycosis: a multicentre retrospective study from India.

OBJECTIVES: To compare COVID-19-associated pulmonary mucormycosis (CAPM) with COVID-19-associated rhino-orbital mucormycosis (CAROM), ascertain factors associated with CAPM among patients with COVID-19, and identify factors associated with 12-week mortality in CAPM. METHODS: We performed a retrospective multicentre cohort study. All study participants had COVID-19. We enrolled CAPM, CAROM, and COVID-19 subjects without mucormycosis (controls; age-matched). We collected information on demography, predisposing factors, and details of COVID-19 illness. Univariable analysis was used to compare CAPM and CAROM. We used multivariable logistic regression to evaluate factors associated with CAPM (with hypoxemia during COVID-19 as the primary exposure) and at 12-week mortality. RESULTS: We included 1724 cases (CAPM [n = 122], CAROM [n = 1602]) and 3911 controls. Male sex, renal transplantation, multimorbidity, neutrophil-lymphocyte ratio, intensive care admission, and cumulative glucocorticoid dose for COVID-19 were significantly higher in CAPM than in CAROM. On multivariable analysis, COVID-19-related hypoxemia (aOR, 2.384; 95% CI, 1.209-4.700), male sex, rural residence, diabetes mellitus, serum C-reactive protein, glucocorticoid, and zinc use during COVID-19 were independently associated with CAPM. CAPM reported a higher 12-week mortality than CAROM (56 of the 107 [52.3%] vs. 413 of the 1356 [30.5%]; p = 0.0001). Hypoxemia during COVID-19 (aOR [95% CI], 3.70 [1.34-10.25]) and Aspergillus co-infection (aOR [95% CI], 5.40 [1.23-23.64]) were independently associated with mortality in CAPM, whereas surgery was associated with better survival. DISCUSSION: CAPM is a distinct entity with a higher mortality than CAROM. Hypoxemia during COVID-19 illness is associated with CAPM. COVID-19 hypoxemia and Aspergillus co-infection were associated with higher mortality in CAPM.

Post COVID sequelae among COVID-19 survivors: insights from the Indian National Clinical Registry for COVID-19.

INTRODUCTION: The effects of COVID-19 infection persist beyond the active phase. Comprehensive description and analysis of the post COVID sequelae in various population groups are critical to minimise the long-term morbidity and mortality associated with COVID-19. This analysis was conducted with an objective to estimate the frequency of post COVID sequelae and subsequently, design a framework for holistic management of post COVID morbidities. METHODS: Follow-up data collected as part of a registry-based observational study in 31 hospitals across India since September 2020-October 2022 were used for analysis. All consenting hospitalised patients with COVID-19 are telephonically followed up for up to 1 year post-discharge, using a prestructured form focused on symptom reporting. RESULTS: Dyspnoea, fatigue and mental health issues were reported among 18.6%, 10.5% and 9.3% of the 8042 participants at first follow-up of 30-60 days post-discharge, respectively, which reduced to 11.9%, 6.6% and 9%, respectively, at 1-year follow-up in 2192 participants. Patients who died within 90 days post-discharge were significantly older (adjusted OR (aOR): 1.02, 95% CI: 1.01, 1.03), with at least one comorbidity (aOR: 1.76, 95% CI: 1.31, 2.35), and a higher proportion had required intensive care unit admission during the initial hospitalisation due to COVID-19 (aOR: 1.49, 95% CI: 1.08, 2.06) and were discharged at WHO ordinal scale 6-7 (aOR: 49.13 95% CI: 25.43, 94.92). Anti-SARS-CoV-2 vaccination (at least one dose) was protective against such post-discharge mortality (aOR: 0.19, 95% CI: 0.01, 0.03). CONCLUSION: Hospitalised patients with COVID-19 experience a variety of long-term sequelae after discharge from hospitals which persists although in reduced proportions until 12 months post-discharge. Developing a holistic management framework with engagement of care outreach workers as well as teleconsultation is a way forward in effective management of post COVID morbidities as well as reducing mortality.

Post-COVID-19 Arterial Thrombotic Events among Three Major Permutations of COVID-19.

BACKGROUND: Post-COVID-19 thrombotic events are a crucial trouble of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, affecting hundreds of thousands of people internationally. Further proof is needed at the chance of putting up COVID-19 thrombotic activities after infection with specific editions of COVID-19. In the gift state of affairs, when the maximum of human beings gets vaccinated, COVID-19 sickness is less likely. However, the remnants of preceding COVID-19 infections are nonetheless a sizeable fitness burden. METHODS: This prospective, observational, comparative, and analytical look at a total of 3,220 COVID-19 sufferers who visited the medical institution. We covered 1,050 sufferers of α-variants; 1,275 sufferers of δ-variants; 895 sufferers of Omicron variations; from June to November 2020, March to July 2021, and January to April 2022, respectively. The affected person's records concerning demography, clinical profile, comorbidities, the severity of the disorder, clinic stay, and vaccination repute were accrued and all sufferers have been accompanied up for 6 months of duration. The sufferers who evolved post-COVID-19 thrombotic events have been approached to gather records regarding demography, comorbidities, the severity of the disease, and vaccination assay. All accumulated information has been tabulated, compiled, and analyzed to examine the post-COVID-19 thrombotic occasions among exceptional variants of COVID-19. RESULTS: A complete of 246 (7.48%) patients [190 (14.90%) of the δ-variant, 41 (3.90%) of the α-variant, and 15 (1.68%) of Omicron version] evolved post-COVID-19 thrombotic occasions at some stage in their comply with-up period. In this observation, distinctly popular post-COVID-19 thrombotic occasions changed into coronary artery ailment (50.00%) which turned followed via cerebral vascular sickness (38.61%), abdominal vessels disease (5.69%), and peripheral artery disease (5.69%). These thrombotic occasions were not unique to any variations of SARS-CoV-2. The distinction of implying the age of patients suffering from post-COVID-19 thrombotic activities became statistically giant (p < 0.05) in comparison amongst all versions. At the time of analysis of COVID-19, 86.17% of sufferers with put-up COVID-19 thrombotic occasions had slight to excessive sickness whilst 13.82% had slight to asymptomatic disorder. The common time length to develop and publish COVID-19 thrombotic events for δ 137.18, Omicron 145.18, and α-version turned 149.85 days. CONCLUSION: Sufferers inflamed with the δ-variant of COVID-19 are greater vulnerable to developing submit COVID-19 thrombotic events with minimum hazard within the Omicron version and intermediate risk within the α-version. The hazard of submitting COVID-19 thrombotic activities is directly proportional to the severity of the sickness.

Prevalence of Pancreatic Exocrine Insufficiency among Patients with Diabetes Mellitus in India.

AIMS: We aimed to assess the prevalence of pancreatic exocrine insufficiency (PEI) in Indian patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) using a unique diagnostic criterion. METHODS: This multicenter study included patients aged ≥18 years with diabetes for at least 5 years. The sociodemographic characteristics, lifestyle habits, and clinical characteristics of patients were assessed. Patients were administered the PEI questionnaire (PEI-Q), and fecal elastase-1 (FE) concentration was measured. Patients were diagnosed to have PEI if they satisfied any two of the following three criteria: (a) a PEI-Q total symptom score of ≥0.60; (b) presence of malnutrition using the European Society of Clinical Nutrition and Metabolism diagnostic criteria for malnutrition; or (c) FE concentration <100 µg/gm stool. RESULTS: This multicenter study included patients aged ≥18 years with diabetes for at least 5 years. The sociodemographic characteristics, lifestyle habits, and clinical characteristics of patients were assessed. Patients were administered the PEI questionnaire (PEI-Q), and fecal elastase-1 (FE) concentration was measured. Patients were diagnosed to have PEI if they satisfied any two of the following three criteria: (a) a PEI-Q total symptom score of ≥0.60; (b) presence of malnutrition using the European Society of Clinical Nutrition and Metabolism diagnostic criteria for malnutrition; or (c) FE concentration <100 µg/gm stool. CONCLUSIONS: Pancreatic exocrine insufficiency (PEI) was found to be prevalent in nearly one-fourth of Indian patients with diabetes, using composite diagnostic criteria.

Post-COVID Syndrome: The Stranger Ghost of Culprit COVID-19.

BACKGROUND: Post-COVID syndromes are the most abundant sequel of coronavirus disease of 2019 (COVID-19) infection, which affects millions of people around the whole world. There is a significant difference observed during the acute phase as well as during the post-COVID period between patients hospitalized with (alpha, delta, or omicron) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant. In the present scenario, when most people are vaccinated, COVID-19 disease is less likely, but the remnants of previous COVID-19 infections are still a vast health burden. MATERIALS AND METHODS: This prospective, observational, comparative, and analytical study included a total of 3,840 COVID-19-infected patients who visited the hospital. We included 1,150 patients of alpha variants, 1,845 patients of delta variants, and 815 patients of omicron variants, from June 2020 to November 2020, March 2021 to July 2021, and January 2022 to May 2022, respectively. All medical data of the study population, including hospital stay and vaccination status, were collected, and all patients were followed up for 6 months of duration. All collected data were compiled and analyzed to compare the post-COVID thrombotic and other events among different variants of COVID-19. RESULTS: Patients infected during the delta variant are the most symptomatic at onset (higher prevalence of fever, dyspnea, cough, myalgia, headache, or gastrointestinal problems) than those infected with the alpha or omicron variant (p < 0.01). A total of 2,830 patients (7.48%) [1,520 (82.38%) of delta variant, 598 (73.37%) of omicron variant, and 712 (60.34%) of omicron variant] developed post-COVID syndrome during their follow-up period out of 3,220 enrolled patients and the difference was statistically significant when compared among variants (p < 0.05). In this study, the highly prevalent post-COVID syndrome was mucormycosis (11.41%), followed by new-onset diabetes (9.89%), pulmonary fiosis (7.67%), ischemic heart disease (6.46%), ain stroke (3.29%), and other thromboembolic disorders (2.37%). CONCLUSION: COVID-19-associated onset symptoms during the delta variant were more severe and highly prevalent, while neurological symptoms (aguesia and anosmia) were more common during the alpha variant. Patients infected with the delta variant of COVID-19 are more prone to develop post-COVID-associated complications with minimal risk in the omicron variant and intermediate risk in the alpha variant. Long COVID-19 requires specific attention for management, irrespective of the SARS-CoV-2 variant.

Discharge Planning for People with Inpatient Hyperglycaemia: A Review on Pharmacological Management.

Inadequate glycaemic control post-discharge is the root cause of readmission in people with diabetes mellitus (DM) and is often linked to improper discharge planning (DP). A structured DP plays a crucial role in ensuring continuing home care and avoiding readmissions. DP should help patients in self-care and provide appropriate guidance to maintain optimal glycaemic control. There is a scarcity of reports and recommendations on the proper DP for people with DM on insulin therapy. The present review provides important consideration based on experts' opinions from the National Insulin and Incretin summit (NIIS), focusing on the effective treatment strategies at the time of discharge, especially for insulin therapy. A review of literature from PubMed and Embase was conducted. The consensus was derived, and recommendations were made on effective DP for patients with DM. Recommendations were drawn at the NIIS for post-discharge treatment for medical and surgical cases, stress-induced hyperglycaemia, elderly, pregnant women, and coronavirus disease 2019 (COVID-19) cases. The committee also recommended a comprehensive checklist to assist the physicians during discharge.

Time required for prophylactic oral care in head and neck cancer patients scheduled for radiotherapy: A single center, prospective cohort study.

BACKGROUND: Prophylactic oral care (POC) before radiotherapy (RT) is an adjunct but an integral process toward preparing patients for RT, however, time to be invested in POC remains unexplored. METHODS: Prospective treatment records were maintained in head and neck cancer patients, who received POC following a standardized protocol with definite timelines. Data collected for oral treatment time (OTT), interruption in RT due to oro-dental issues, future extraction(s), and incidence of osteoradionecrosis (ORN) up to 18 months after treatment were analyzed. RESULTS: Three hundred thirty-three patients, 275 males and 58 females, mean age 52.45 ± 11.2 years were included. Mean OTT was 21.0 ± 6.2 days and was influenced significantly with the number of extractions (p < 0.00). There was no interruption in RT schedule due to oro-dental issues. Five patients were diagnosed with ORN. CONCLUSION: Performing POC as demonstrated aid in timely removal of nidus of infection(s), perform RT as scheduled, and maintain satisfactory oral health through the survivorship of patients.

Influence of speech aid prosthesis with speech therapy on speech outcomes in adult patients with persisting velopharyngeal insufficiency: A retrospective analysis.

STATEMENT OF PROBLEM: Prosthetic intervention with a speech aid prosthesis (SAP) along with speech therapy has been reported to improve speech outcomes in patients with persisting velopharyngeal insufficiency (VPI). However, little is known regarding the impact of this treatment on different speech parameters over time in adult patients with VPI. PURPOSE: The purpose of this retrospective study was to evaluate the change in speech parameters after rehabilitation with an SAP and speech therapy in adult patients with VPI using subjective and objective tests. MATERIAL AND METHODS: Patients above 16 years of age who had received prosthetic treatment for VPI and had complete speech assessment records between 2017 and 2020 were included in the analysis. After completion of the prosthetic treatment, speech therapy comprising 2 sessions per week of 45 minutes was provided by a speech pathologist. Speech evaluation was performed using tests that included speech intelligibility calculation, nasal pinch test, audible nasal air emissions, acoustic analysis, and the nasalance check. Assessments were done at 4 time intervals: T0: without an SAP; T1: 1 week with an SAP; T2: 1 month with an SAP; and T3: 3 months with an SAP. A descriptive analysis was followed by a comparison between groups using the Friedman test for subjective assessments and repeated measures ANOVA for objective tests (α=.05). RESULTS: Of 10 individuals who had received an SAP, 5 participants, 2 men and 3 women with a mean age of 38 years were included in the analysis. Statistically significant improvement in mean scores was observed from T0 to T3 concerning speech intelligibility (P<.001), hypernasality (P<.001), audible nasal air emission (P<.001), mean fundamental frequency (P=.034), shimmer percentage (P=.004), and nasalance (P=.004). Improvement in jitter percentage was not statistically significant (P=.218). CONCLUSIONS: An SAP along with speech therapy should be considered as a conservative and effective treatment option for addressing speech issues in adult patients with VPI.

Post Covid-19 Sinonasal Candidiasis: A Crisis Within the Pandemic.

The aim of this study was to find out the association of sinonasal candidiasis and Covid-19 infection. A prospective observational study was conducted at a tertiary care centre from April to September 2021, involving all patients with invasive candidiasis of the paranasal sinuses having a history of Covid-19 infection. A total of 18 patients of covid associated sinonasal candidiasis among the 475 cases of fungal rhinosinusitis were studied. All patients had involvement of nose and sinuses and 2 patients had orbital involvement with no loss of vision, while 3 had intracranial extensions and 1 had pulmonary involvement. Mandible was involved in 1 patient alone, while the maxilla and palate were involved in 5 patients. 15 patients were hypertensive, 12 diabetics and 1 had aplastic anaemia. Cultures showed that 8 patients had C. parapsilosis, 5 had C. albicans, 3 had C. tropicalis and 2 had mixed fungal infections. All patients underwent surgical debridement and antifungal administration. They were followed up for a minimum of 3 months. There was only one mortality (with aplastic anaemia), rest 17 were disease free at the time of writing this article. This is perhaps the first case series of post covid sinonasal candidiasis in the world. Invasive sinonasal candidiasis is a newer sequela of COVID-19 infection. Uncontrolled diabetes and over-zealous use of steroids at the time of Covid-19 are few of the known risk factors. Early surgical intervention and anti-fungal treatment should be sought for management.

COVID Associated Invasive Aspergillosis.

To study the possible association between invasive fungal sinusitis (aspergillosis) and coronavirus disease. An observational study was conducted at a tertiary care centre over 6 months, involving all patients with aspergillosis of the paranasal sinuses suffering from or having a history of COVID-19 infection. 92 patients presented with aspergillosis, all had an association with COVID-19 disease. Maxillary sinus (100%) was the most common sinus affected. Intraorbital extension was seen in 34 cases, while intracranial extension was seen in 5 cases. Diabetes mellitus was present in 75 of 92 cases. All had a history of steroid use during their coronavirus treatment. New manifestations of COVID-19 are appearing over time. The association between coronavirus and aspergillosis of the paranasal sinuses must be given serious consideration. Uncontrolled diabetes and overzealous use of steroids are two main factors aggravating the illness, and both of these must be properly checked.

Chest HRCT Assessment of COVID-19 Patients in Vaccinated versus Nonvaccinated Patients: A Comparative Study in a Tertiary Care Hospital.

Coronavirus disease 2019 (COVID-19) has turned out to be the most devastating viral disease that the world has encountered for the past century. The World Health Organization (WHO) declared it a pandemic on March 11, 2020. The disease mainly spreads through respiratory droplets which makes social distancing a primary tool of prevention. Many variant strains have emerged up since the pandemic started and the Delta variant is responsible for recent surge of cases in second wave of COVID-19 in India. Mass vaccination is the most efficacious precautionary measure that can be applied to stop the transmission and generate herd immunity. Vaccination does not give 100% prevention from infection, but it halts the severity of infection. Vaccine is the boon amidst the mayhem. Our study highlights that those vaccinated (particularly two doses) had clinically mild symptoms and mild computed tomography severity score (CTSS) with a speedy recovery. Those unvaccinated had moderate to severe symptoms with moderate to severe CTSS (>8) often requiring hospital admission and having poor prognosis. Thus, vaccine helps reduce the health burden of the already strained health care system. Immunization visit can also be used as an opportunity to disseminate message to encourage behavior, to reduce transmission risk of COVID-19 virus, to identify the signs and symptoms of disease, and to provide guidance on what to do.

Giant Parathyroid Adenoma: Are They Different?

Primary hyperparathyroidism is a common endocrinology anomaly which involves head and neck region. The diagnosis and treatment of parathyroid adenoma however still remains a challenge. Giant parathyroid adenomas are rare and involve more surgical expertise. Retrospective study was carried in Departments of ENT and Endocrinology, SMS Medical College and Hospital, Jaipur. Records of patients operated between 2010 and 2019 were evaluated and analysed for size and site of parathyroid adenomas, biochemical parameters, intra-operative findings and postoperative course. Tumours with size > 3 cm were termed as giant parathyroid adenomas and this is a rarity in literature. Records of 79 patients were found to be complete. Out of these 9 had giant parathyroid adenomas: 4 left inferior, 2 right inferior, 1 ectopic location (superior mediastinum) and 1 each in left and right superior glands. The size, symptomatology and biochemical parameters are discussed in light of available literature. Giant parathyroid adenomas are a rare entity and their behaviour are same as of non giant parathyroid adenomas. In the view of literature published on pub Med, this is found to be largest case series on parathyroid Adenoma considering size more than 3 cm.

Genomic profile of SARS-CoV-2 Omicron variant and its correlation with disease severity in Rajasthan.

Background: Omicron, a new variant of Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2), was first detected in November 2021. This was believed to be highly transmissible and was reported to evade immunity. As a result, an urgent need was felt to screen all positive samples so as to rapidly identify Omicron cases and isolate them to prevent the spread of infection. Genomic surveillance of SARS-CoV-2 was planned to correlate disease severity with the genomic profile. Methods: All the SARS-CoV-2 positive cases detected in the state of Rajasthan were sent to our Lab. Samples received from 24 November 2021 to 4 January 2022 were selected for Next-Generation Sequencing (NGS). Processing was done as per protocol on the Ion Torrent S5 System for 1,210 samples and bioinformatics analysis was done. Results: Among the 1,210 samples tested, 762 (62.9%) were Delta/Delta-like and other lineages, 291 (24%) were Omicron, and 157 (12.9%) were invalid or repeat samples. Within a month, the proportion of Delta and other variants was reversed, 6% Omicron became 81%, and Delta and other variants became 19%, initially all Omicron cases were seen in international travelers and their contacts but soon community transmission was seen. The majority of patients with Omicron were asymptomatic (56.7%) or had mild disease (33%), 9.2% had moderate symptoms, and two (0.7%) had severe disease requiring hospitalization, of which one (0.3%) died and the rest were (99.7%) recovered. History of vaccination was seen in 81.1%, of the previous infection in 43.2% of cases. Among the Omicron cases, BA.1 (62.8%) was the predominant lineage followed by BA.2 (23.7%) and B.1.529 (13.4%), rising trends were seen initially for BA.1 and later for BA.2 also. Although 8.9% of patients with Delta lineage during that period were hospitalized, 7.2% required oxygen, and 0.9% died. To conclude, the community spread of Omicron occurred in a short time and became the predominant circulating variant; BA.1 was the predominant lineage detected. Most of the cases with Omicron were asymptomatic or had mild disease, and the mortality rate was very low as compared to Delta and other lineages.

Establishment of SMS Dengue Severity Score.

BACKGROUND: Dengue infection is a disease that progresses rapidly to life-threatening conditions. Our goal was to develop a practical scoring system based on clinical profiles and routine tests to predict the severity of infection. METHODS: This cross-sectional observational study included 500 patients with dengue infection. Patient demographics, clinical symptoms, regular laboratory tests, and results were collected. Dengue infections are divided into three classes, depending on their severity: dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS). Based on the total score, patients were divided into three severities. RESULTS: Patients with DSS and DHF scored higher with worsening clinical features and routine laboratory tests compared to DF. Clinical predictors of severity include older age, increased white blood cell (WBC) count, increased hematocrit, increased prothrombin time, decreased platelet count, decreased blood pressure, presence of peri-gallbladder (GB) edema, third space loss, hepatomegaly, and other organ involvement. The severity range is 0-12, and the score is 0-3 for DF, 4-8 for DHF, and 9-12 for DSS. Based on the derived scores, patients were classified according to their original severity in 63% of cases. CONCLUSION: This dengue infection severity scores correctly classified patients according to their original severity grade of DF, DHF, or DSS. This scoring system helps to quickly assess dengue infections and start treatment according to the correct severity category.

Oral and dental care before radiotherapy: Guidelines and development of a time-bound protocol.

Involvement of multidisciplinary team is the mainstay in the holistic treatment outcome in head and neck cancer patients. Achieving a state of oral health is regarded as an essential treatment goal before radiation therapy but, it may get overlooked due to many competing priorities, lack of multidisciplinary facilities and/or incoordination, and limited overall awareness with regards to means of achieving oral health and in a time-bound manner and its relevance in improving quality of life in cancer survivors. Radiation inflicts an immense amount of damage upon the entire maxillofacial complex and consequently oral treatment after radiotherapy may remain untreated and/or undertreated. It is, therefore, vital to eliminate oral foci of infections well within a time frame before radiation so that tumor prognosis is not compromised.This article describes the current guidelines combined with a time-bound protocol developed in our center to not only prepare a patient for conventional radiotherapy but also to provide a logical perspective towards the feasibility of the oral rehabilitation post-cancer cure. The protocol aims to maximize the quality of life in head and neck cancer survivors by; patient education, minimizing preventable oral complications, and retaining strategic teeth for function, aesthetics, speech, and prosthetic support. The time-bound pre-radiation oral care protocol is rational, achievable, and is aligned towards the sustained oral health care goals in head and neck cancer patients and can be utilized as a useful resource in multidisciplinary head and neck cancer care facilities.

Twenty Years of Insulin Gla-100: A Systematic Evaluation of Its Efficacy and Safety in Type 2 Diabetes Mellitus.

INTRODUCTION: This systematic review aims to present the current evidence base with respect to the initiation and intensification of insulin therapy with glargine 100 U/mL (Gla-100) compared to other insulins in people with type 2 diabetes mellitus (T2DM). METHODS: A systematic literature search of PubMed (MEDLINE), EMBASE, and the Cochrane Central Register of controlled clinical trials databases was performed to identify studies published up to September 30, 2020 that compared the effects of Gla-100 to that of other insulin regimens in people with T2DM. Relevant information pertaining to the predefined outcomes of interest was extracted. Glycated hemoglobin (HbA1c) change and response rates along with overall hypoglycemia incidence were the primary efficacy and safety outcomes of interest. RESULTS: Seventy-nine studies (63 interventional and 16 non-interventional) in which Gla-100 was either initiated in previously insulin-naïve patients (n = 57) or used in an intensified regimen (n = 22) were identified and evaluated. In insulin-naïve patients, most studies demonstrated that Gla-100 was significantly better compared with premixed insulins and similar compared with neutral protamine Hagedorn (NPH) insulin, second-generation basal insulins, co-formulations, and other first-generation basal insulins in terms of the primary efficacy parameters. Overall hypoglycemia risk with Gla-100 was significantly lower compared with NPH, premixed, coformulation, and other first-generation basal insulins and significantly higher compared with second-generation basal insulins. In studies with intensified regimens, efficacy outcomes with Gla-100 were significantly better compared with insulin detemir (IDet); similar compared with NPH, second-generation basal insulins, co-formulations; and with premixed insulins. In these studies, overall hypoglycemia risk with Gla-100 was significantly lower compared with IDet and comparable to NPH, premixed insulins, co-formulations, and second-generation basal insulins. In addition, most intensification studies also revealed a significantly lower risk of nocturnal hypoglycemia with Gla-100-based regimens versus NPH and premixed insulins and a significantly greater risk compared to second-generation basal insulins. CONCLUSIONS: The evidence presented in this review suggests that Gla-100 is an effective option for both insulin initiation and intensification strategies used in the management of T2DM.